DIVISION OF WORKERS COMPENSATION

KS DEPARTMENT OF LABOR
800 SW JACKSON ST STE 600
TOPEKA KS 66612-1227
Phone: 785-296-3441 – Fax: 785-296-0839
Web Site: www.dol.ks.gov

Election Not to Accept Coverage Under

Kansas Workers Compensation Act by Employee Who Owns
10% or More of Corporate Stock of Corporate Employer.

NOTICE: To be processed, All entries on this form must be completed. All

entries, except signatures, must be neatly printed in black ink.
NOTE: This Election is effective upon receipt by the Kansas Division of
Workers Compensation.

To the Kansas Division of Workers Compensation, you are hereby notified that:

Name of Employee Electing Out of Act: ____________________________________________________

Social Security Number of Employee: _____________________________________________________

Corporate Employer's Name and Address: __________________________________________________

Telephone Number: (______)________________ Type of Business:_____________________________

The above named employee states that he/she owns 10% or more of the corporate stock of the above
corporation and elects, pursuant to K.S.A. 44-543, not to accept coverage under the Kansas Workers
Compensation Act. The above named employee recognizes that by signing this form he/she is not
covered under the Kansas Workers Compensation Act.

_____________________________________________
Valid Signature of Employee Electing Out of Act

_____________________________________________
Date Signed by Employee

Federal Privacy Act Disclosure Section 7(a)(2)(B)

The mandatory requirement that social security numbers be included on forms filed with the Division of Work-
ers Compensation is permitted by Section 7(a)(2)(B) of the Federal Privacy Act of 1974, since our regulations which
require its disclosure were in existence before January 1, 1975. The number is used as a means of identifying all
the various records in the Division of Workers Compensation pertaining to an individual.
The use of social security numbers is made necessary because of the large number of applicants who have
similar names and birth dates, and whose identities can only be distinguished by the social security number.

K-WC 50 (Rev. 10-04)